Adapting the SAFE Program to the Needs and Preferences of Rural CBOC Providers, Veterans and Families Michelle D. Sherman, Ph.D. SCMIRECC Advisory Board Meeting February 2011

Investigators Ellen Fischer, Ph.D. – Little Rock epidemiologist (co-PI) Ursula Bowling, Psy.D. – OKC psychologist Russell Smith, Ph.D. – Wichita Falls CBOC psychologist (telepsychology provider) Peggy Hudson, Ph.D. – OKC psychologist (formerly Lawton CBOC) Thanks to the VA Office of Rural Health (ORH) and the South Central MIRECC for their funding of this project

VA’s Uniform Mental Health Services Package (2008) “family consultation, family education, or family psycho-education…be provided for those who need them at all VA medical centers and very large CBOCs”

SAFE Program Support And Family Education 18-session family education program for those who care about someone living with SMI/PTSD Originally funded by SCMIRECC clinical education grant (1999) and currently in its 3 rd edition (2008)

Selected as “Best Practice” by VACO and numerous trainings and ongoing consultations are provided –Strong interest by Local Recovery Coordinators As of mid-2010, approximately 50 VA medical centers are providing SAFE Entire curriculum is available for free download:

However, SAFE was developed and has primarily been provided in large, urban medical centers.

Project Aims Assess organizational barriers and mental health provider preferences related to CBOC-based implementation of SAFE Elicit the perspectives of rural veterans living with SMI or PTSD and their families regarding family participation in SAFE, structural and cultural barriers to participation, and preferences regarding delivery Tailor SAFE and its implementation to meet rural needs

Methods 5 one-hour key informant phone interviews with staff from 2 rural CBOCs (one small and one large) –1 psychiatrist –1 psychologist –1 nurse –2 social workers

Interview Domains Knowledge/experience in providing family education Comfort/readiness to provide family education Desire for training/supervision Recommendations regarding how to engage families Perceived barriers to rural provision

Six 90-minute focus groups (3 with veterans and 3 with family members) at 3 sites: –Large CBOC –Small CBOC –Medical Center (only for veterans who drive over 90 miles)

26 veterans –96% male –Mean age of 56 –69% Caucasian –77% self- report PTSD, 50% depression 23 family members –96% female; 89% wives –Mean age of 54 –69% Caucasian

Focus Group Domains Perceived appropriateness of family involvement Perceived benefits/drawbacks for veterans and family Preferences regarding program structure, e.g., modes of delivery, locations, logistical preferences (e.g., time of day) Perceived logistical barriers to family participation Recommendations regarding how to engage families

Overview of Findings Rural veterans, families, and providers express strong interest in family services Desired content was not substantially different from that of urban families Barriers exist, but are not insurmountable

Challenges and Suggested Solutions Structural –Personnel –Space Logistics –Competing demands, transportation, time of day –Children / child care Rurality Attitudes and fears

Important needs include: –Dedicated clinician time –Clinic space –Preliminary training & ongoing consultation/support –Understanding of and a commitment to families living with mental illness/PTSD –Understanding of rural culture –Patience and perseverance

Technology Almost all of our Veterans and families expressed strong preference for in-person services –Parallels findings from report by the National Alliance for Caregiving. (November 2010). Caregivers of veterans: Serving on the homefront.

Products Implementation Toolkit Appendix on Provision in a Rural Area or VA CBOC –Addresses 6 key themes –Assists administrators and rural clinicians in anticipating barriers and brainstorming solutions to rural implementation –Available on SAFE Program website Webinar on our findings, toolkit, and available consultation